HIV Prevention Among Adolescents Using Evidence-Based Approaches

This edition of the Technical E-Update explores HIV prevention among adolescents using evidence-based approaches. Peter Piot, former UNAIDS executive director once said,  “there is no silver bullet to HIV-prevention,” particularly when it comes to matching successes in behavioral strategies to those of the bio-medical advancements that now are available. There has to be a more effective way for programs to respond when standing at the crossroads where social culture, individual-behavior and health sciences intersect in the context of prevention efforts. This can only be done by reflectively assessing the impact by specific interventions and programs.  In an effort to better support this, research efforts are being invested more now than ever before in qualitative assessments on the efficacy of HIV prevention programs and their critical components to assist implementers to match their field work with evidence based responses.  This is particularly important in the context of programs serving adolescents, a sub-group representing the highest rate of new annual infections globally! 

In a published study in the journal AIDS and Behavior, “Common Principles Embedded in Effective Adolescent HIV Prevention Programs,” effective and evidence based adolescent HIV prevention programs were subjected to quantitative analysis. The aim of the study was to determine and extract the common principles or elements that are cross cutting in these pre-packaged programs that can be attributed to their success. In doing so, 10 core principles have been identified and are now being appreciated as essential components to evaluate the effectiveness of prevention curricula, activities and interventions with young people across various settings. 

It is important to note that these principles convey not only behavioral and cognitive change but the development of more mature ways of functioning, which is critical in the adolescent context.  The researchers take into consideration that HIV-prevention for youth must address aspects of normative adolescent development issues such as impulse control, lack of future orientation, novelty and sensation seeking, peer pressure, decision making skills and the difficulties in maintaining a sense of positive self-worth. The following highlights these essential principles which the study affirms to be central to the success of acclaimed evidence based prevention programs, as well as how they can be demonstrated in the context of a program. The phrases used to capture each principle were conceptualized by the researchers based on a coding process as part of the research methodology: 

Believe in your own worth and your right to a happy future: 

In each of the programs, there was an assumption that positive feelings about yourself support the ability to resist peer-pressure and act in a self-protecting manner.  Being able to identify self-worth apart from approval or love from another person supports this, as well as being able to see hope in the future. Thus programs must help young people identify personal values, act in a manner consistent with their goals, strengthen inner sources of self-esteem and the behavioral skills to say “no” to pressures surrounding high-risk activities. 

Distinguish fact from myth:

HIV prevention cannot happen if people lack basic knowledge about the virus, its transmission and the methods of protection. Prevention programs must incorporate didactic components that not only teach accurate information about HIV and AIDS but also reveal the common myths and false assumptions that are prevalent within their community. It is equally critical to ensure that the facts that are known are consistent with updated information. Beyond this, programs must articulate that all wise decisions must be based on accurate information, thus should incorporate skills on how to independently access trusted resources for self-education. 

Evaluate options and consequences:

This principle is a critical part of the decision making process. Each program that was studied argued that self-protective behaviors have desirable long-term outcomes and are therefore preferable to unsafe behaviors which often have short term rewards.  The philosophy behind this principle is to teach participants how to distinguish the difference between “rationalization” from “sound reasoning” and the effects that follow. 

Commit to change:

Once an individual is able to evaluate options, the individual needs to make a choice, which can most effectively be adhered to through an expressed personal commitment. Since behaviors that put people at risk are often pleasurable and can occur impulsively, programs aim to reinforce the concept of personal commitment, often linked to the recognition of personal value and acknowledgment of personal vulnerabilities – dispelling the dangerous perception that “it cannot happen to me.” 

Plan ahead and be prepared: 

Risky situations often arise unexpectedly. Unless programs equip young people with the skills to be prepared, they will face difficulty in maintaining personal commitments to reduce risk. The programs under review in the study integrated skills development activities to assist participants to rehearse and understand thought patterns, communication skills and resist and cope with peer pressure. Some explored how to anticipate and avoid risky situations as well as take universal precautions through messages like “always carry a condom.”

Practice self-control:

Given that sexual intercourse involves stages or sequences of verbal and non-verbal behaviors, and recognizing how difficult it can be to stop in the middle of such a sequence it is essential for adolescents to have a strategy that is cognizant of this. Self-control requires awareness of one’s emotional states and recognition of stimulation triggers supported by behavioral rehearsals, which prepares to either avoid or break the sequence where risks are high. Programs must inform participants on the link between substance use and the weakening of self-control as well to allow them to make decisions what will allow them to maintain sound decisions.

Know pleasurable alternatives to high-risk sexual activity:

The notion of self-control is further enhanced when there are pleasurable alternatives besides providing youth with only two extremes: abstinence or unsafe sex.  Developing skills and perceptions that make safe sexual contact enjoyable are present in all the evidence-based programs.  Simultaneously, programs help youth identify independently that many emotional needs are often linked to sex including stress reduction, approval, closeness and love and that there are alternative ways to meet these needs that would not put them at risk of infection. 

Negotiate verbally and nonverbally:

By encouraging verbal negotiation, youth are more able to interrupt a sequence of events that might put them at risk. To implement verbal negotiation, youth must be acquainted with what to say and how to say it. They must have matching verbal and non-verbal behaviors in order to assert themselves with conviction. Still, they need to know that in doing so they are not refusing the value in that relationship – a common assumption that saying “no,” will drive someone away.  Verbal negotiation supports personal commitment to self-protection, strengthens the principles behind improving self-worth and helps shape social networks that are supportive to their decisions to practice prevention. 

Choose to limit your freedom:

This principle, though controversial in phrasing, is necessary for all self-enhancing behaviors that involve self-discipline in the face of pleasure. Since youth often resist rules externally imposed by authorities, it is essential for them to take the responsibility for creating their own rules and limits. When limitations are seen as self-determined and necessary for protecting health and achieving goals, youth are more likely to accept them. 

Act to help others protect themselves:

This final common principle in the evidence based program analysis, endorses the sense of personal responsibility that participants have for others, especially their partners. Some of them take on the approach of “friends don’t let friends engage in risky behaviors” while others include the importance of informing past partners and protecting future partners with information related to personal health, risk, and HIV status. 

The 10 principles identified in the study embrace motivational factors, problem solving and decision making skills development. They incorporate behavioral and developmental concepts of autonomy, maturity, critical thinking and social responsibility – rather than asserting externally driven rules, key messages and instructions.  It is critical for implementing programs to review current strategies used in HIV-prevention programming with youth to assess the complete presence of these 10 principles, proven in their impact.  

It is important to note that re-designing or adopting these programmatic strategies does not mean that an implementing program cannot tailor their responses based on community specific needs. These concepts can be universally adopted, and the study affirms that it is encouraged to maintain flexibility in the delivery of the activities according to the audience – so long as the concepts within each of the principles is covered in the most relevant and receivable manner. 

The following resources aim to support your understanding and adoption of evidence based prevention strategies targeting adolescent populations.  As you explore these documents in the context of your program remember: HIV Prevention must be an integrated component of work you do to mitigate their vulnerability and risk in the long term.  

1. Science and Success in Developing Countries:

Holistic Programs that Work to Prevent Teen Pregnancy, HIV and STIs: This publication highlights 10 programs from seven developing countries around the world. All 10 programs produced beneficial changes in sexual risk behaviors among sexually experienced youth while six of these programs also delayed the initiation of sex. This report will assist you in deconstructing programs to isolate the components that facilitate change to be applied to your programs context. 

2. One2One:

One2one™ is LVCT-Health’s peer led (for-youth, by-youth, with-youth) innovative & evidence based program me offering comprehensive quality sexual and reproductive health direct services & literacy to over one million adolescents & youth (10-24 years) in Kenya annually. One2one utilizes a complimentary mix of multi-media approaches that include digital platforms, direct health and HIV service delivery, training and capacity building targeting youth. 

To access their online resource center click here.

3. Advocates for Youth Sex Education Resource Center: 

Is an online clearing house of programs with complete guides to implementation, interactive exercises, participant handouts and supplemental facilitators’ guides.  The online resource center contains the following downloadable resources to support your work with community members – be it children, youth or their caregivers: 

• Life Planning Education (Life skills program)
• Toolkit for creating safe spaces for sexual minority groups
• Implementation guide for the Teen for AIDS Prevention (TAP) peer education program
• Parent-Child Communication curricula 

“There is no place Like Home” Newsletters to assist parents to talk about sexual health issues within the home 

To visit the resource center click here

4. Tuko Pamoja:

“We are Together!” The second edition of this Kenya Adolescent Reproductive Health curriculum created by PATH, is designed with the aims of delaying sexual debut, promote reproductive health, and equip adolescents with life skills that will support making informed and healthy decisions. Designed for ages 10 to 19 this curricula includes sections that are appropriate for ages 10 to 14 which are specified in the document: 

Click here to download the PDF 

5. Chill Club Curricula:

Developed by PSI in Kenya to support child-parent-teacher communication on adolescent sexual health issues. This curricula, targeting ages 10 – 14, is an excellent resource touching on the essential topics that young people grapple with through the sensitive time in their life: This includes issues of puberty, different types of relationships and emotions relating to peers, gender stereotypes and the facts and myths about pregnancy, HIV and STIs. The sessions also incorporate skill building discussions on self-esteem, assertiveness, decision-making, goal-setting, exploitation and dealing with peer pressure. 

To download this file as PDF click here